Kalia Yang and her boyfriend Andy Moua, background, watch an ultrasound image of their twin babies performed by technician Rita Siudak, foreground, at St. Josephs Hospital recently. The couple, who are married in the Hmong tradition, is expecting their babies in November.

By Karen Herzogh, Milwaukee Journal Sentinel

Posted Aug. 29, 2011, at 4:22 p.m.

MILWAUKEE, Wis. — During a home visit with a social worker, in her second trimester of pregnancy, Kalia Yang stares at a chart that shows how many packs of cigarettes an unborn baby is exposed to if the mother smokes: Sixty-seven packs, or 1,350 cigarettes, if she smokes five cigarettes a day in the course of a full-term pregnancy.

Yang is expecting twins in November. She no longer smokes; she quit as soon as she suspected she was pregnant. It’s a big win for the babies and a small victory in Milwaukee’s battle against infant mortality.

Health officials will take it.

In some corners of the city, smoking during pregnancy is seen as a positive that leads to a smaller baby and a smoother delivery. In reality, smoking can cause miscarriage, premature birth and low birth weight. Some women consider breast-feeding uncivilized and unattractive. They don’t grasp its benefits, including possibly providing protection against sudden infant death syndrome.

Knowledge gaps, which exist everywhere, even in a community’s most stable neighborhoods, can be life-threatening if a woman is at risk of having a baby born too early or too small.

Health professionals call this “health literacy.”

It’s the ability to obtain and understand accurate health information, to manage one’s behavior and to navigate the health care system. It can mean knowing when to see a doctor. It can mean asking the right questions, getting a timely diagnostic test or properly filling out a medical form.

Research shows a strong link between health literacy, health outcomes and medical expenditures.

“You can be very literate and be health illiterate,” said Jackie Tillett, a nurse midwife and director of the Midwifery & Wellness Center at Aurora Sinai Medical Center in Milwaukee.

“Parenting is about being empathetic with your child and caring for your baby. Many people who never graduated from high school are good parents. And I know physicians with advanced degrees who are not good parents.”

A pregnant woman who understands how to care for herself, gets regular prenatal checkups and has support to navigate the health care system has the best chance of delivering a healthy baby.

“It’s not about being stupid or uneducated,” said Nicole Angresano, vice president for community impact at the United Way of Greater Milwaukee, which has joined the city’s fight against infant mortality. “Information is only as good as it is understandable.”

Yang chose the Wheaton Franciscan-St. Joseph Women’s Outpatient Center for this pregnancy because her sister-in-law had a good experience there when she gave birth. This is Yang’s third pregnancy. The previous two ended in miscarriages, both in the first trimester. Yang blames her miscarriages on smoking, but no one can say for sure why she didn’t carry the babies to term.

Yang first came to the Women’s Outpatient Center because she was bleeding and didn’t know she was pregnant. She was having a miscarriage. She returned several months later to confirm a second pregnancy, but she miscarried again before her first checkup. This pregnancy is the first with regular checkups, frequent ultrasounds and the guidance of a social worker, she said.

Yang, 23, and her boyfriend of six years, Andy Moua, 25, are taking extra precautions this time, trying to do everything right. The couple is in a committed relationship in the Hmong tradition.

For now, the two are focused on learning about pregnancy and healthy babies.

Literacy skills are the strongest predictor of health, more than age, income, employment status, education level, race or ethnicity, according to the Partnership for Clear Health Communication. Older patients, recent immigrants, people with chronic diseases and those living in poverty are especially vulnerable to low health literacy.

One study shows that 40 percent of what shapes a person’s health is related to behavior, a higher proportion than genetics (30 percent), social-environment (20 percent) and access to care (10 percent).

To address behavior, changes are necessary on both sides of the doctor-patient relationship. A patient may not ask questions or share critical information because she doesn’t want to feel dumb. A doctor may assume a message is getting through and not take the time to make sure.

Most brochures that doctors give women to help them better understand pregnancy and possible complications are written at a 10th-grade reading level or higher, said Geoffrey Swain, medical director for the Milwaukee Health Department. But one in five people can’t read above a fifth-grade level, he said.

“Low health literacy makes it harder to get good medical care.”

Meanwhile, a pregnant woman’s friends or family members may pass along misinformation. They may not know doctors now say a baby should sleep on his or her back to help prevent SIDS. Or, one generation may pass a negative stereotype about breast-feeding to the next.

“Health literacy can be overcoming culture,” said Mary Mazul, a nurse midwife at the Women’s Outpatient Center at St. Joseph. “We all have our own ideas. No matter what culture we come from, what our mothers taught us, not all things are correct.”

Health care providers are homing in on how to better help women have healthy babies.

Obstetrician Tina Mason often writes things down for her patients.

“If you have a patient with a medical problem, the stress of the problem can impact their ability to understand,” said Mason, who also is program director of Aurora Sinai Medical Center’s obstetrics and gynecology department.

“I approach a patient woman to woman, not as a hotshot doctor.”

At the end of appointments, she may ask patients to repeat what she told them so she’s sure they understand. She also coaches medical residents to speak to patients in plain language.

Efforts are under way both locally and nationally to get reader-friendly information into the community.

“We need to reach them in churches, beauty salons and the grocery store, not just the doctor’s office,” said Janice Whitty, chief of obstetrics for Nashville General Hospital at Meharry, who spoke during an Infant Mortality Summit in Milwaukee in May. “Many women only go to the doctor’s office if they have a problem.”

Social media, such as Twitter and Facebook, are valuable tools to help educate women about healthy pregnancy, she said.

Pregnant women also can get free weekly text messages on their cellphones. The messages in English or Spanish are timed to specific stages of pregnancy. The text4baby service is from the National Healthy Mothers, Healthy Babies Coalition.